OBS AND GYNAE HISTORY TAKING (SELECTED CASES)

A. History taking in a pregnant woman:

Personal Data
1. NASTROMA
2. Gestational Age(GA),LMP,EDD
3. Parity/LCB
PC/HPC
4. Any complaints?
DETAILS OF PRESENT PREGNANCY
5. Is Patient booked?
6. Indication for booking
7. GA at booking
8. Any foetal movements?
9. GA at first perception of foetal movement
10. Any TT administered?
11. Investigations done in present pregnancy Viz:FBC,USS,Blood
Grp,Genotype
12. Drugs presently on: Folic acid, Fesolate, Antimalarial
PAST OBS HISTORY
13. Any ANC in previous pregnancies?
14. Type of delivery: home, hospital,eventful/uneventful
15. Birth weight and sex
16. Any complications: Labour/Puerperium, Abortion(GA),
Stillbirth(GA)
17. History of twinning
GYNAE HISTORY
18. Katamania (e.g. K13 5/28)
19. Flow, regularity, Dysmenorrhoea, Dyspareunia

PAST MEDICAL HISTORY AND ANY MEDICAL CONDITION

FAMILY HISTORY
SOCIAL HISTORY
SYSTEMIC REVIEW
SUMMARY

B. HISTORY IN A PATIENT WHO COMPLAINTS OF URINARY

INCONTINENCE:
BIODATA
1. NATROMA
2. Lmp/parity/Lcb
HPC
3. Onset of incontinence?
4. Total/Partial incontinence?
5. Urge incontinence?
6. Overflow incontinence?
7. Amount of urine passed?
8. Frequency, dysuria, Lower abdominal Pain, Haematuria?
9. When was last confinement?
10. Length of labour during LCB?
11. How was baby delivered?
12. Outcome of labour: Stillbirth, Well, Neonatal Death?
13. Where was delivery done?
14. Was there an insitu catheter
15. OTHER PREDISPOSING FACTORS:
i. Trauma to genital region:Gishiri cut, Coital injury,
penetrating vaginal inj
ii. Any packing of vagina with caustic salts?
iii. Any irradiation to genital regions?
iv. Any vulval sores following infection to genitalia?
v. Any vaginal insect bite?
vi. Any history of measles?

GYNAE HISTORY
16. Katamania
17. Flow, regularity, dyspareunia, dysmenorrhoea?
18. Any vaginal discharge, STI?
19. Use of contraceptives?
20. Has Pap smear been done?
PAST MEDICAL/SURGICAL HISTORY
21. Known DM, HTN, SCD, Asthmatic?
22. Any surgical operation: Pelvic floor repair, Myomectomy etc?
23. Any form of medication presently on?

FAMILY/SOCIAL HISTORY
24. Smoking, Alcohol?
25. Occupation of husband?

CAUSES OF VVF
-OBS;- TRAUMA...PROLONGED OBSTRUCTED LABOUR
-OPERATIVE VAGINAL DELIVERY
-DESTRUCTIVE OPERATION
-SYMPHYSIOTOMY
-CAESERIAN SECTION
-GISHIRI CUT
-LYMPHOGRANULOMA VENERUM
-CONGENITAL OCCURENCE
-PENETRATING VAGINAL INJURIES
PACKING VAGINA WITH CAUSTIC SALTS
-GENITAL TUMOURS
-IRRADIATION

C. HISTORY TAKING IN A PATIENT WITH PV BLEEDING

BIODATA
1. NATROMA
2. LMP/Parity
 HPC

3. Duration of bleeding
4. Amount of bleeding?
5. Any associated abdominal pain?
6. Any dyspnoea, weakness, dizziness?
7. Passage of grape like vesicles through the vagina?
8. Any excessive vomiting?
9. Any ankle swelling?
10. Any abdominal swelling?
GYNAE HISTORY
11. Katamania
12. Flow, regularity, dysmennorhoea, dyspareunia?
13. Any history of abortions?
14. Any vaginal discharge/STD
PAST OBS HISTORY

15. Complications?
16. Last confinement?
URINARY SYMPTOMS
17. Frequency, dysuria, haematuria
18. Incontinence: stress, urge, overflow.

PAST MEDICAL/SURGICAL AND DRUG HISTORY.

D. HISTORY TAKING IN A PATIENT WHO HAS BEEN DRAINING LIQUOR

BIODATA
1. NATROMA
2. LMP/LCB/Parity
3. EGA, EDD
HPC
4. Colour of liquor?
5. Amount?
6. Odour?
7. Duration of drainage?

ANTECEDENT EVENTS AT TIME OF RUPTURE

I At rest, during physical activity, following coitus?

8. Any investigations or procedure performed during pregnancy:

pelvic exam, Amniocentesis.
9. Any contractions or Foetal movements
10. Any fever
11. Any vaginal discharge before
drainage
12. Any bleeding during the pregnancy
HISTORY OF PRESENT PREGNANCY
13. Booked patient, GA at booking
14. Indication for booking
15. Any foetal movements and at what
GA first perceived
16. Any TT received
17. Investigations done in the
pregnancy
18. Drugs presently on.
PAST OBS HISTORY
19. Any antecedent care?
20. Types of delivery?
21. Any complications?
22. Pre-term or Full-term?
GYNAE HISTORY
23. Katamania
24. Flow, regularity, dysmenorrhoea,
dyspareunia.
25. Contraceptive history
26. Abortions? When, how?
27. PAST MEDICAL HISTORY
28. FAMILY/SOCIAL HISTORY

E. HISTORIES TAKING IN A PATIENT WITH COMPLAIN OF SOMETHING

COMING DOWN FROM HER VAGINA.
BIODATA
1. NATROMA
2. Parity
3. LCB/LMP

HPC
4. Duration of condition
5. When is it worse
6. Reducibility
SYSTEMIC REVIEW
7. Frequency of micturition
8. Urge incontinence
9. Stress incontinence
10. Constipation
11. Any difficulty in passing faeces
12. Any backache
13. When is it worse
14. When is it better
15. Easy tiredness
16. Any haematinics used
GYNAE HISTORY
17. Katamania
18. Flow/Regularity
19. Any PV bleeding
20. Postcoital/Intermenstrual PV
21. Any Dyspareunia
22. Any vaginal discharge
23. Colour of discharge
24. Amount of discharge
25. Any associated vulval pruritus
26. Use of contraceptives
PAST OBS HISTORY
27. Parity/LCB
28. History of macrosomic babies
29. Any instrumental delivery
30. Any perineal tears/injuries
31. PAST MEDICAL/SURGICAL HISTORY
32. FAMILY/SOCIAL HISTORY

CAUSES OF UV PROLAPSE
Congenital weakness
Prolonged labour
DM Neuritis
Menopause/Post menopause
Instrumental delivery
Lifting heavy objects
Pelvic mass/Tumour
PARTURITION
(i) Multiparity
(ii) Premature bearing down before full cervical dilatation
(iii) Prolonged traction during vacuum aspiration

F. HISTORY TAKING IN A PATIENT WITH COMPLAIN OF INABILITY TO

GET PREGNANT
BIODATA
1. NATROMA
2. LMP

HPC
3. How long has patient been unable to get pregnant
4. Has patient ever been pregnant before
5. Frequency of coitus per week
6. Is coitus protected/unprotected
7. Any douching after coitus
8. Does patient live with husband
9. Has any form of contraception been used in the past
10. Any history of
abortions....circumstances surrounding abortion
11. Any history of vaginal
discharge,STI,Genital infection, fever
12. Any breast discharge
13. Any neck swelling, Heat/Cold
intolerance
14. Any abnormal hair distribution or
excessive hair growth
15. Any history of uterine fibroids
16. Does patient know safe/Unsafe
period or Ovulatory periods
17. Husbands work
18. Does husband have other
wives/Girlfriends
19. Any child by other wives? Girlfriends
20. Has husband had any infection,
Trauma or operation to genital region
GYNAE HISTORY
21. Katamania
22. Flow/Regularity/Dysmenorrhoea
23. Any Dyspareunia
24. Any frequency of micturition
25. Any urge incontinence
26. Any Dysuria
PAST MEDICAL/SURGICAL HISTORY
27. History of DM, HTN,SCD
28. Any surgeries
29. Any form of drug treatment
presently
30. FAMILY/SOCIAL HISTORY

CAUSES OF INFERTILITY
FEMALE FACTORS
(i) CERVICAL
a. Sperm antibodies
b. Mass occluding cervix
c. Cervicitis

(ii) TUBAL
a. STD
b. Vaginal discharge
(iii) UTERINE
a. Fibroids
b. Intrauterine mass
(iv) OVULATORY
a. Dysmenorrhoea
b. Galactorrhoea
c. Diabetes Mellitus

MALE FACTORS
 (i) Epididymo-orchitis
(ii) Past surgery to genitals
(iii) DM
(iv) Drugs
(v) Trauma
(vi) Premature ejaculation
(vii) Testicular torsion
(viii) Varicocoele
(ix) Tight underwear
(x) Excessive prolactin
(xi) Undescended testis
(xii) Hypo/epi-spadia

HISTORY TAKING IN A PATIENT WHO COMPLAINS OF GENERAL BODY

WEAKNESS IN PREGNANCY

BIODATA
1. NATROMA
2. LMP/EGA/EDD
HPC
3. Duration of weakness
4. GA at onset of weakness
5. Any blood loss during pregnancy
6. Amount of blood lost
7. GA at time of loss
8. Dizziness/Fainting attacks
9. Dyspnoea
10. Swollen legs
11. Headache
12. History of fever
13. Genotype
14. Any anorexia/Nature of nutrition
HISTORY OF PRESENT PREGNANCY
15. Is patient booked
16. GA at booking
17. Indication for booking
18. Any foetal movement
19. GA at which 1st foetal movement was
felt
20. No of TT received
 21. Investigations done in pregnancy
22. Drugs presently on
PAST OBS HISTORY
23. Any ANC in previous deliveries
24. Type of delivery
25. GA at delivery....Preterm/Term
26. Birth weight
27. Sex
28. Complications
GYNAE HISTORY
29. Katamania
30. Flow/Regularity
31. Vaginal discharge/Pruritus/STD
32. Dyspareunia
33. Any abortions
34. Any form of contraception
35. PAST MEDICAL/SURGICAL/DRUG
HISTORY
FAMILY/SOCIAL HISTORY
36. Occupation of husband
37. History of twinning/SCD

CAUSES OF ANAEMIA IN PREGNANCY

1. Physiological haemodilution
2. Fe2+/Folate deficiency
3. Malnutrition
4. Successive pregnancies at frequent intervals
5. Malaria
6. Chronic blood loss
7. Haemoglobinopathies

G. HISTORY TAKING IN A PREGNANT PATIENT WHO IS LARGE FOR

DATE

BIODATA
1. NATROMA
2. LMP/Parity/GA

HPC
3. Hx of excessive vomiting
4. Hx of uterine fibroids
5. Hx of twinning in patient
6. Family Hx of twinning
7. Hx of DM in patient
8. Family Hx of DM
9. Previous history of macrosomic babies
10. Birth weight of babies
11. Pre-pregnancy weight of patient
12. Present weight of patient
13. Any Hx of abnormal baby in patient
14. Family Hx of abnormal baby in
patient
15. Any family Hx of unexplained
stillbirth
16. Hx of stillbirth in patient
HISTORY OF PRESENT PREGNANCY

17. GA at booking
18. Indication for booking
19. Quickening
20. No of TTs received
21. Investigations done in
pregnancy/Drugs
HISTORY OF PAST PREGNANCIES
22. ANC
23. Types of delivery
24. Pre or full term
25. Sex
26. Complications
GYNAE HISTORY
27. Katamania
28. Flow/regularity
29. Contraception
30. PAST MEDICAL/SURGICAL/DRUG
HISTORY
31. FAMILY AND SOCIAL HISTORY

CAUSES OF LARGE FOR DATE

(i) Wrong dates
(ii) Multiple pregnancy
(iii) Polyhydramnios
(iv) Diabetes Mellitus
(v) Fibroids in pregnancy
(vi) Hydatidiform mole
(vii) Foetal abnormalities....anencephaly
(viii) Familial
(ix) obesity

H. HISTORY TAKING IN A PREGNANT PATIENT WITH COMPLAIN OF

ABDOMINAL PAIN
BIODATA
1. NATROMA
2. LMP/Parity/GA
 HPC
3. Onset of pain and GA at onset
4. Site/Duration/Nature of pain
5. Relieving/Aggravating factors
6. Associated factors/Radiation
7. Any Hx of trauma to abdomen
8. Any vaginal bleeding
9. Any bleeding from any other sites in the body
10. Any foetal movement
11. Frequency of urination
12. Quantity of urine produced
13. Hx of HTN before or during
pregnancy
HISTORY OF PRESENT PREGNANCY
14. Is patient booked
15. GA at booking
16. Indication for booking
17. Quickening at what GA
18. No of TT received
19. Investigations done in pregnancy
PAST OBS HISTORY
20. ANC
21. Type of delivery
22. Full or pre term
23. Sex and birth weight of children
24. Any complications

GYNAE HISTORY
25. Katamania
26. Flow/Regularity
27. Use of contraceptives
28. PAST MEDICAL/SURGICAL/DRUG
HISTORY
29. FAMILY AND SOCIAL HISTORY
EXAMINATION OF GRAVID UTERUS (LEOPOLDS)
A. INSPECTION:
(i) Exposure;
Expose patients up to the pubic hairline inferiorly
Patients cloth should go below the breasts superiorly
(ii) Describe the abdomen:
Uniformly/ Gravidly enlarged
Avoid using uniformly distended because this connotes
pathology
Any striae gravidarum? Mention the region found( striae
is due to increased cortisol)
Any linea nigra? Mention region and extent
Describe the umbilicus
Any foetal movements seen?
Any other feature seen

B. SYMPHYSIO-FUNDAL HEIGHT:
Johnsons rule; SFH in cm after 20wks GA is directly proportional
to the gestational age

SFH Answers 2 questions;

(i) Normality of the pregnancy
(ii) Rate of growth of the pregnancy
METHODOLOGY;
(a)Locate the fundus starting from the xiphisternum using the
ulna border of the left hand until a resistant is encountered,
place the tape under the ulna border of the hand with the
inch side facing the examiner and leave the tape
(b)Locate the upper border of the symphysis pubis in the mid
line using the index finger of the right hand
(c) Take the measurement with the inch side and turn to read in
cm
(d)REPORT: e.g. SFH is 26cm which is consistent with 26wks of
intrauterine pregnancy and compartible with the EGA
(e)If the SFH is greater or less than 2wks EGA, then it is
incompartible ;
Greater than 2wks; see causes of large for date above
Less than 2wks:
(i) Wrong date
 (ii) Intrauterine growth restriction
(iii) Oligohydramnios
(iv) Congenital anormaly

OTHER METHODS OF ESTIMATING EGA

1. Fundal height estimation (using anatomic landmarks):
(i) Level of symphysis pubis-12wks
(ii) Level of umbilicus-22wks
(iii) way b/w i and ii-16wks
(iv) way b/w i and ii-18wks
(v) Just above ii-24wks
(vi) Level of xyphoid process-36wks
(vii) B/w ii and vi- use finger estimation
2. Quickening; GA at which 1st foetal movement is perceived by the
mother
(i) Multi para-16wks
(ii) Primi-18wks
3. USS
4. X-RAY: using ossification centers
(i) Knee bone-36wks
(ii) Tarsal bones-36wks
(iii) Tibia-38wks
(iv) Talus and calcaneous-40wks
C.PALPATION
1. Determination of the poles of the foetus;(facing the patient)
(i) Palpate the fundus to determine its content by stabilising
with one hand and palpating with the other
(ii) Palpate sides with 1 hand stabilising at the other side at
least thrice on each side; Determine the back and front of
the foetus (regular smooth side-back, irregular side-front)
- Determines the lie of the foetus.
(iii) Palpate lower uterus to determine the presenting aspect
of the foetus;
(i) Round hard mass ballotable and firm(head)
(ii) Smooth regular mass, firm but not
ballotable(buttocks)

If the presentation is cephalic then determine descent

using rule of five fifths by finger measurements; If 2/5 or less is
palpable, then the head is engaged (indicating that the foetal head is
capable of passing through the pelvis)

If presentation is cephalic, then determine the position:

the description of the location of the designated point of the presenting
part (occiput) of the foetus in the maternal pelvic quadrants.
IMPORTANCE;

(i) Determines how the baby will emerge in the birth canal
(ii) Determines how smooth/not smooth/ not possible the
mechanism of labour can occur.
(iii) If position is occipito-posterior(Rt/Lt) it leads to long
rotation and therefore prolonging labour

FOETAL HEART TONE

Using the pinard to determine whether the heart tone is

present or not and whether regular or not. (Safer not to determine rate
as a student)

The back of the foetus is targeted over the scapula (maximum

tone)

(i) If presentation is breech then place pinard above the

umbilicus
(ii) If presentation is cephalic then place pinard below the
umbilicus

THANK PATIENT AND REPORT FINDINGS:

(i) SFH
(ii) LIE
(iii) PRESENTATION
(iv) POSITION
(v) FOETAL HEART TONE

PREPARED FOR ISMA LIBRARY BY

ANAS BALA UMAR

2009

Special thanks to ADEBOLA ZAKARI .O.

MAY ALLAH MAKE THIS BENEFICIAL TO ALL AND MAY HE CONTINUE TO

HELP, GUIDE AND SIMPLIFY THINGS FOR US

AMEEN